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Click to edit Master text styles Incentive-Based Wellness Programs: Understanding the Rules of the Road Second level Behavioral Perspective Third level Fourth level Fifth level David Anderson, PhD LP Innovations in Workplace

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David Anderson, PhD LP Innovations in Workplace and Community Wellness

April 7, 2014

Incentive-Based Wellness Programs: Understanding the Rules of the Road

Behavioral Perspective

Improving HEALTH Through Employer Leadership

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Improving HEALTH Through Employer Leadership

  • HERO

– Chairman, Research Committee – Member, Board of Directors – Founding member

  • StayWell Health Management

– EVP & Chief Health Officer – Co-founder

David R. Anderson, PhD LP

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Improving HEALTH Through Employer Leadership

What Drives Behavior?

  • Psychology 101 – “Animal Drives”

– Drive 1: biological drives like food, water, sex – Drive 2: reward/punishment, i.e. extrinsic motivation

  • Psychology 201 – “Human Needs”

– Drive 3: intrinsic motivation

  • Highest levels in Maslow’s hierarchy of needs
  • Autonomy, competence, relatedness

– Self-determination theory – Deci & Ryan

  • State of absorption in an activity for its own sake

– Sense of engagement, happiness, fulfillment, timelessness – Optimal level called “flow” by Mihaly Csikszentmihalyi

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Improving HEALTH Through Employer Leadership

Extrinsic vs. Intrinsic – Why Care?

  • Controlled vs. Autonomous Motivation

– Controlled: Seduced, coerced, pressured – Autonomous: Volition, endorsement, interest, deeply valued – Some even choose to die for valued beliefs

  • Limits of “wellness incentives”

– Controlled motivation buys compliance – Compliance depends on incentive

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Improving HEALTH Through Employer Leadership

What’s the Evidence on Incentives?

  • Incentives increase short-term compliance

– HA, activity participation, simple short-term actions

  • Long-term change requires “intrinsic motivation”
  • r large ongoing incentive

– Large external incentives may decrease intrinsic motivation

  • People work long and hard for valued goals

– Health is not a “passion” motivating most people until it’s gone – Large outcome-based financial incentive may increase perceived value

  • f employer’s health goals… but little evidence yet exists
  • Initial compliance may become intrinsic over time

– Requires strong cultural alignment , e.g. seat belt use, smoking

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Improving HEALTH Through Employer Leadership

Smoking Trends Among U.S. Adults

15% 25% 35% 45% 1965 1970 1974 1980 1985 1990 1995 2001 2006 2010 2012

42.4% 37.4% 37.1% 33.2% 30.1% 25.5% 24.7% 22.8% 20.8% 19.3% 18.0%

Source: National Health Interview Surveys, 1965–2012.

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Improving HEALTH Through Employer Leadership

Supportive Environment Matters

Impact of Culture and Communications

27% 33% 41% 44% 51% 65% 33% 37% 53% 41% 51% 69%

0% 20% 40% 60% 80% 100%

Weaker Strong

HA Participation Rate (%)

Comm. Culture Comm. Culture Comm. Culture

Non-Cash Incentives Cash Incentives Benefits-Integrated Incentives n=4 n=16 n=16

Reference: Seaverson ELD, Grossmeier J, Miller TM, Anderson DR. The role of incentive design, communications strategy and worksite culture on health assessment participation. American Journal of Health Promotion, 2009;23:343-352.

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Improving HEALTH Through Employer Leadership

The “Three Pillars” of Engagement

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Improving HEALTH Through Employer Leadership

ACA Regulations and Wellness

  • Incentives are NOT a wellness program

– Large incentives are health plan design feature

  • ACA driving rapid growth in incentives

– Usage, amounts, requirements – Trend toward outcome-based designs

  • Behavioral and policy issues

– Limited evidence of long-term behavioral impact – Concerns: fairness, trust, extrinsic motivation

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Improving HEALTH Through Employer Leadership

Guidance for a reasonably designed employer-sponsored wellness program using outcomes-based incentives: Consensus statement of the Health Enhancement Research Organization (HERO), American College of Occupational & Environmental Medicine (ACOEM), American Cancer Society and American Cancer Society Action Network, American Diabetes Association, and American Heart Association.

Journal of Occupational and Environmental Medicine. 2012;54(7):889-896.

Reasonably Designed Wellness Program